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For too long, the ballooning problem of childhood obesity has beenoverlooked in the examining room. But as associated health risks once confinedto adulthood begin to creep into the pediatric population, primary careproviders can no longer ignore the problem—even when parents do.
New data indicate that parents often fail to recognize when their childrenhave a weight problem.
In a recent British study involving 300 children, researchers found that60% of normal-weight mothers failed to realize when their child wasover-weight or obese, compared with 43% of overweight mothers. Alison Jeffery,MSc, of Peninsula Medical School, Plymouth, U.K., and colleagues report that44% of normal-weight fathers failed to recognize overweight in their children,compared with 67% of over-weight fathers. In this study, reported at therecent American Diabetes Association Scientific Sessions, the parents' weightdid not necessarily correlate with how they perceived their children'sweight.
This was not the first study to identify a startling incidence of parentalmisperceptions regarding children's weight. Researchers from New York MedicalCollege found that, despite accurate knowledge of excess weight as a healthrisk and the importance of healthy eating habits, manyparents—especially those of overweight children—maintaininaccurate perceptions of their own children's weight. In the November 2003issue of Obesity Research, Debra Etelson, MD, and colleagues reportedon their survey of 83 parents, 23% of whom had overweight children. Only 10.5%of parents with overweight children perceived their child's weight accurately,compared with 59.4% of other parents.
These findings beg the question: Are parental misperceptions about theirchildren's weight really just denial? Jeffery believes not. "I thinkmany parents truly did not recognize their children as overweight, becausenowadays overweight is seen as the norm in society," she says.
Other experts suggest that parents have their heads in the sand when itcomes to their perception of hefty children. "Parents believe what theywant to believe," says Etelson. "There's got to be some degree ofdenial going on."
In some circumstances, parents actually perceive overweight in theirchildren favorably. "Parents tend to believe a chubby child iscute," says Etelson.
Moreover, individuals from select ethnic backgrounds traditionally haveequated "chubbiness" inchildren with good health."Anecdotally, immigrants tend to worry about their children who aresmall because oftentimes, in their native countries, the health of thesechildren was more vulnerable. It depends on their level ofacculturation," says William Dietz, MD, director of the Division ofNutrition and Physical Activity at the Centers for Disease Control andPrevention (CDC).
CHANGING MISPERCEPTIONS
"We know that parents of overweight children usually don't recognizethat their children are overweight. Thus, talking about health risks is oftenpremature," Dietz says. Pediatricians must first get parents ofoverweight children to acknowledge that a problem exists.
"Seeing is believing," advise some experts—parents seeingdisproportionately large gains on their children's growth chart, that is."For many pediatricians, the growth chart is kind of a blueprint, thething that should be right there when you open the chart," Etelson says."That way, pediatricians can show parents what a gain of 10 pounds meansin the scheme of things."
The American Academy of Pediatrics (AAP) also espouses the use ofstandardized measurements. In its first-ever policy statement on theprevention of pediatric obesity, published in the August 2003 issue ofPediatrics, the AAP's Committee of Nutrition urged pediatricians toevaluate body mass index (BMI) annually. Routinely measuring BMI may be adrastic change in practice for many pediatricians. "Several years ago,only 20% of pediatricians were measuring BMI," Dietz notes. But, headds, most pediatricians today recognize the necessity of adopting thepractice.
IDENTIFYING HIGH-RISK PATIENTS
That childhood obesity results from a combination of several factors haslong been established. New studies illuminate two factors that place childrenat increased risk for overweight and obesity.
Having obese parents places children at the greatest risk of overweight,according to a recent study by Stanford University School of Medicineresearchers. The team of scientists, led by W. Stewart Agras, MD, tracked 150children and their parents from birth through age 5 years. Sixty-four percentof subjects with overweight parents became overweight, compared with 16% ofsubjects whose parents' weight was in the normal range. Results were publishedin the July 2004 issue of the Journal of Pediatrics.
Low socioeconomic status is yet another risk factor for childhood obesitythat has received attention lately. At the ADA Scientific Sessions,researchers of the Studies to Treat or Prevent Pediatric Type 2 Diabetes(STOPP-T2D) project announced results of their large-scale pilot study thatexamined weight and associated health risks of 1,700 school children (averageage of 13.6 years) from schools in Texas, North Carolina, and California. Ineach of the participating schools, the majority of students qualified for freeor reduced-cost lunch.
Findings were disheartening. Forty-two percent of the subjects wereidentified as having blood glucose levels indicative of pre-diabetes, and49.3% exhibited a BMI above the 85th percentile for their age and sex."This is a very high-risk population," says principal investigatorFrancine Kaufman, MD, who heads the Center for Diabetes, Endocrinology &Metabolism at Children's Hospital of Los Angeles.
MANAGING OVERWEIGHT AND OBESITY
As the first line of defense in disease prevention, primary care has anopportunity to take an active role in counseling patients and their parents onweight management. But data suggest that this does not happen nearly as oftenas it should.
The Department of Health and Human Services (DHHS) noted in their HealthyPeople 2010 initiative that a mere 3% of patients receive counseling on weightmanagement during office visits. The literature on this topic stops short ofblaming physicians for not addressing childhood weight problems, noting thatnutrition training in medical schools remains inadequate.
So where do primary care providers begin? It can begin with modestlifestyle recommendations that work within the family's existing framework,experts suggest.
"I try to find out from them what's realistic and then set up a plan.For example, I ask `What do you like to do, and where do you live?' If theydon't have access to a park or fitness center, I might say to them, `Could youwalk the stairs in your apartment building?'" Etelson says.
Experts warn not to expect too much too soon. "Focus on making smalljumps of progress. Otherwise, you and your patients get verydiscouraged," says Alison Hoppin, MD, of Massachusetts GeneralHospital's Weight Center.
For example, patients may not be ready to eliminate sodas completely fromtheir diet, but they may be willing to cut back to one a day. The same appliesto television viewing. "The AAP suggests no more than 1 or 2 hours of TVdaily," says Hoppin. "I think shooting for 1 hour is a bettergoal."
But, she warns, "that can be a huge change in people'slifestyle." And it's a change patients and their parents may not bewilling or ready to take on. How can a pediatrician determine patients' andparents' readiness to accept lifestyle modifications? "By listening hardfor the answer, rather than dictating `ideal' information," Hoppinsays.
The upshot for pediatricians confronting overweight patients? Communicatingwith patients and parents about weight loss in a positive manner mayultimately result in improved outcomes. "Focus on healthy lifestyles,and on the patient's strengths. Talk about the advantages of exercise:improved strength, athletic abilities," suggests Daniel Bronfin, MD,vice chairman of pediatrics at New Orlean's Ochsner Clinic.
Despite the best efforts of primary care providers, they cannot alwaysmanage challenging weight problems alone. "Lifestyle change involves ateam," says Kaufman. "It's not about a doctor who has a 15-minutetimetable and has to do all the other aspects of the exam."
Growing numbers of primary care providers are referring obese patients tocomprehensive weight management programs. Typically, such programs take amultidisciplinary approach, with input from exercise physiologists,nutritionists, social workers, and physicians.
Etelson offers this practical advice for pediatricians whose patients mightbenefit from such a program: "Find out which programs or services mightbe available within a reasonable area and have them at your disposal so thatpatients can walk out with a phone number," she says.
Currently, most insurance companies do not cover the cost of weightmanagement programs. But with increasing awareness of the serious and costlyhealth risks that can befall obese children, this situation may change.
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